Family Attachment Scheme ReflectionINTRODUCTION:A chronic illness is defined as ‘a long-term condition which can be treated but not cured’[1]. As a second-year medical student, the majority of what I have learned in this incredible course so far has been concerned, primarily, with the somatic aspects of medicine. I completely understand that this content is laying solid foundations for us to build on as we advance throughout the 5 years and beyond, and while I have thoroughly enjoyed this part of the course, I can’t deny that this Family Attachment Scheme has been one of my favourite experiences to date. As one of my first dealings with real patient contact, the family attachment scheme opened my eyes to the countless ways a chronic illness can affect someone’s life. In lectures, we learn the ins and outs of a disease, how it originates and what we can do to treat it, but I can see how easy it could be to forget that this list of signs and symptoms in front of you, is a real person, deserving of our respect and compassion. I consider myself extremely lucky, as the patient I was paired with has been a dream to deal with, and I surmise the things I have learned from him will be applicable throughout my career in the medical profession. Over the last few months, I have had the privilege of getting to know and build a rapport with Bill, an 87-year-old man who suffers from type 2 diabetes. Visiting Bill over the past few months, my partner and I have had the privilege of gaining insights into his illness, the impact it has on him and his family, and the experience they have had with health and social care in Ireland. Type 2 diabetes ‘is characterized by a progressive insulin secretory defect due to insulin resistance, which increases the body’s demand for insulin in order to retain glucose homeostasis’[2]. For Bill, regulating his diabetes is a priority in his day to day life. Despite the demands of his illness, Bill remarkably remains one of the most optimistic people I have ever had the pleasure of meeting. Reflecting on my experience of the family attachment scheme has been an exceptionally enjoyable experience. BACKGROUND & FIRST IMPRESSIONS: As my partner and I made our way to Bill’s home for our first visit, I was brimming with emotion. A blend of apprehension and excitement accompanied me as we followed the directions google maps, hoping we were on the right path. The fear of the unknown weighed slightly on my mind. Was this man going to want to talk about his illness to two inexperienced medical students? Would he expect us to know more than we did? Should I let him know that I have been fastidiously studying his medical history sheet twice a day in preparation of this visit? Or would that show how incredibly nervous I was? These somewhat baseless fears were swiftly dissipated within a few minutes of meeting Bill and his wife Sheila. We had arrived a few minutes early, and after 2 unanswered knocks, we were worried they had forgotten the appointment altogether. Fortunately, Bill and Mary pulled up in their car just in time. We were warmly greeted, and Bill cracked one of his, now familiar, jokes that put us at ease immediately. Their home was tastefully decorated, and I couldn’t help comparing it fondly to my own Nana’s home. The Sacred Heart was on display amidst adorable family photos, including Bill and S’s 5 children and 3 grandchildren. We settled at the kitchen table, where we were offered tea and cakes, and Bill proceeded to educate us on his condition. I i I I I I I I I I I I IA cork native, Bill was raised above a lively pub. He recounted his childhood with an ever-present smile and continued to the romantic story of how he and S met at the age of 18. Bill and S lived a happy life, raising their 5 boisterous children between Clonmel, Waterford and finally Cork city.Bill tells us his only hospital stay, as a young adult, was for a cholecystectomy in 1982. He divulged the pain he experienced for weeks after the surgery and how he had an instinctive desire to spend as little time in the hospital as possible. In Bill’s experience, if ever his relatives went into hospital for more than a few days, they tended not come home. Bill informs us, that overall, he had excellent health as a young man. This declaration is followed by a swift tap of the wooden table in front of him, as if saying this aloud was tempting fate in some way. S chimed in at this point, telling us Bill ‘has a bit of a superstitious streak in him’. Answered by a playful eye-roll from Bill, it isn’t hard to recognise that this couple are best friends as well as a husband and wife team. This strong relationship was moving to see, and re-enforced the fact that illnesses effecting one member of a family must, undoubtedly, have some sort of effect on their loved ones. ‘Spouses occupy a dual role in the coping process, as primary provider of support to the ill partner and as a family member who needs support in coping with the illness-related stresses he or she is experiencing’ [3]. Thankfully, both Bill and S were very forthcoming with their experiences of Bill’s diagnosis.DIAGNOSIS:In 1998, Bill and S had seen 4 of their children graduate from UCC and their youngest son, having had ‘itchy feet’ all his life, went travelling soon after finishing his leaving cert. Bill had just retired and started spending more time at the local golf club. One day, while showering in the clubhouse after 18 rounds, a friend of Bill’s (who happened to be a doctor) noticed he had a sizeable boil on his lower back. Bill had spotted the boil previously but assumed it would go away itself. The friend advised Bill to get it checked out just in case it was anything more sinister. Heeding this advice, Bill visited his GP the following week. Despite a subtle nudge from my partner, Bill did not go into much detail about receiving his diagnosis. Initially, I considered this may be a contentious topic, perhaps the diagnosis itself was not delivered in a professional manner. Upon reflection, both Bill and S have mentioned the high level of care they receive from their GP so I suspect it may just be something this upbeat man did not feel like dwelling on for too long, on this particular Wednesday afternoon. Instead, he focused on the disbelief he experienced when he learnt his maternal grandmother suffered from Type 2 diabetes for most of her life. There are several lines of evidence to suggest that type 2 diabetes in elderly adults has a strong genetic predisposition. ‘Elderly patients with a family history of diabetes are more likely to develop the disease as they age’ [4]. He recounts his grandmother visiting every Christmas Eve and ‘pouring herself a generous glass of Jameson’, and he was astounded her diabetes was never discussed. He has since learned he also has a first cousin who suffers from Type 2 diabetes.COPING WITH THE DIAGNOSIS:Type 2 diabetes is, undeniably, a serious condition and its diagnosis alters a patient’s life in countless ways. Whilst this also rings true for Bill, he concedes that he considers himself luckier than most because he was in his late 60’s when he was diagnosed. S tells us she is certain it would have been a ‘whole different ball game’ if he were diagnosed in his 20’s or 30’s. Explaining, it would have been a whole lot harder to deal with Bill’s condition if they were in the middle of raising their five children and Bill was still working full time. The fact that they were now living alone, and Bill had already retired, meant that both Bill and S had more time to devote to dealing with the new demands of insulin injections, blood glucose monitoring, etc. After 20 years, the couple are well accustomed to the procedures involved. S proudly shows us a timetable she made for Bill, outlining which insulin injection he should take and the appropriate amounts. He takes 12 units of NoVo rapid before his breakfast each morning, 8 units of NoVo rapid before his lunch, 12 units of NoVo rapid before his tea and 14 units of Toujeo before bed. Before administering each of these, Bill must check his blood glucose levels. S can recite this timetable off by heart, but Bill doesn’t seem as sure of it. On a later visit, I notice this timetable is written on the back of 2006 calendar- after 12/13 years Bill still relies on S to remember these things better than himself. This, again, shows me the approach they take to his illness, it involves S just as much as Bill when it comes to regulating it. They are a team in every sense of the word.IMPACT: ?     Physical: Bill constantly reiterates how lucky he considers himself in life, despite his illness, he is grateful for his family’s good health throughout the years. As we ask him to open up about how the disease impacts on his day to day to life, he admits he found the injections and finger pricking a strange procedure in the beginning, but now he is used to it. He was prescribed insulin tablets for a few years but says the injections don’t bother him. In fact, he found it hard to swallow so many tablets a day, and nearly preferred the change to injections.The main impact Bill mentions is, what he calls, ‘the hypos.’ These are periods of time when Bill has low blood glucose levels leading to hypoglycaemia. He often gets them in the middle of the night, waking up drenched in sweat. Bill explains how frightening this was, the first time it happened. He had no idea what was going on and felt extremely weak. S agrees that she was quite confused when Bill woke her at 2am in a panic, having soaked his pyjamas in sweat. Shortly after, the GP explained to Bill and S exactly what had happened, and they learned more about what caused Bill’s blood glucose level to dip.‘Hypoglycaemia is one of the most feared complications of diabetes treatment… Approximately 90% of all patients who receive insulin have experienced hypoglycaemic episodes [5].’ They now keep a box with KitKat bars and bottles of Club Lemon near their bed, in order to bring Bill’s glucose levels back up if he has one of these ‘hypos’ during the night. He also knows that if he skips a meal, he’s at risk of having one, but Bill jokingly assures us he never misses a meal if there’s anything he can do about it!Knowing how to manage these potential hypoglycaemic attacks, and being accustomed to the injection schedule, Bill and S have learned to manage the illness efficiently and are doing all the appropriate things to alleviate the symptoms of diabetes.?     Social: Bill and S are a very social couple, they mention various outings they have been on in recent weeks, at our visits, and we often find it tricky to find a suitable time to schedule a visit due to their busy social calendar. I was curious to know if Bill’s diagnosis had impacted this aspect of the couple’s life.In response, we were treated to an anecdote. Around 2 years ago, the couple were attending a dinner party in their local golf club. The event began at 6 in the evening, so Bill and S had lunch that afternoon and spent the evening getting ready for the dinner. They arrived just before 6 and had a drink as they chatted amongst friends. Unfortunately, (‘in true Irish fashion’-Bill adds) the dinner which was set to be served at 6 had still not made an appearance by half past 7. Bill started to feel faint and shaky, and noticed himself sweating through his shirt. He had to sit down and rest as he waited for his dinner to come. Even after eating his dinner, Bill still felt off and the couple left the event early to head home.Bill’s greatest concern was that he had ruined S’s night. S laughs at this, assuring him he did no such thing and tells us that evening taught them that Bill needs to have a sandwich or something light before they go out to an event in the evening. The following year, Bill did exactly this and reveals that, despite his sandwich at 5pm, he was starving by the time his dinner was served several hours later!This optimistic couple refuses to let diabetes interfere with their social lives. They quickly recognise what could potentially go wrong and find pragmatic ways to remedy these before they become an issue, all the while maintaining a positive attitude and never stopping to complain. It is incredibly interesting to see the correlation between a patient’s attitude towards their illness and their quality of life. If BILL were to dwell on the misfortune of his diagnosis, he would spend less time doing the things he loves with S.PERSONAL REFLECTION: The Family Attachment Scheme has been my first taste of what it will be like to build a trusting, professional relationship with a patient, to be confided in, and to understand a chronic illness from the points of view of both the sufferer as well as their family members. Bill and S have proven that the diagnosis of a chronic illness does not have to be met with enormous sorrow. They see it as just one small part of their lives, and something they can deal with. They truly have an attitude of gratitude and I have ascertained an immeasurable amount of information from them, that I could not have learned in any number of textbooks and I am certain that I will carry it with me throughout my career.To conclude, I feel privileged to have gained Bill and S’s trust as they opened up to me about their lives. Among numerous other things, this has reminded me that the patient is a complex human being who can’t be categorised, and I am left with the realisation that I have so much left to learn before I can become a well-rounded doctor of any kind. ‘He who studies medicine without books sails an unchartered sea, but he who studies medicine without patients does not go to sea at all’ [6]. The Family Attachment Scheme has been an exceedingly educational experience and something I’ll be forever grateful for.Bibliography: [1.] A chronic illness is defined as ‘a long-term condition which can be treated but not cured’.The Health Service Executive ‘HSE Transformation Programme: 4.1 Chronic Illness Framework’ July 2008. p.2 2[2.]  Type 2 diabetes ‘is characterized by a progressive insulin secretory defect due to insulin resistance, which increases the body’s demand for insulin in order to retain glucose homeostasis’.Zhao, Y., Xu, G., Wu, W., & Yi, X. (2015). Type 2 Diabetes Mellitus- Disease, Diagnosis and Treatment. Journal of Diabetes & Metabolism, 06(05).http://doi.org/10.4172/2155-6156.1000533[3.] Spouses occupy a dual role in the coping process, as primary provider of support to the ill partner and as a family member who needs support in coping with the illness-related stresses he or she is experiencing.Annals of Behavioural Medicine, Volume 16, Issue 2, 1 January 1994, Pages 122–130,https://doi.org/10.1093/abm/16.2.122[4.] There are several lines of evidence to suggest that type 2 diabetes in elderly adults has a strong genetic predisposition. Elderly patients with a family history of diabetes are more likely to develop the disease as they age.The Journals of Gerontology: Series A, Volume 56, Issue 1, 1 January 2001, Pages M5–M13https://doi.org/10.1093/gerona/56.1.M5[5.] Hypoglycaemia is one of the most feared complications of diabetes treatment… Approximately 90% of all patients who receive insulin have experienced hypoglycaemic episodes.Clinical Diabetes 2006 Jul; 24(3): 115-121.https://doi.org/10.2337/diaclin.24.3.115[6.] He who studies medicine without books sails an unchartered sea, but he who studies medicine without patients does not go to sea at all.William Osler, Direct Quote.